Medicare / Medi-Cal News

Don't forget to check Medicare patients' eligibility! Traditional Medicare doesn't require much pre-authorization, but Medicare HMO's often do. Medicare could deny your claim if your patient switches to an HMO, then the HMO could deny your claim because you didn't have prior authorization.

When documentation is required to process a Reopening, providers must submit the request as a Written Reopening with a completed "Reopening Form" or through Endeavor. If a request is more complex, beyond clerical errors or omissions, it is appropriate to submit a Redetermination via the "Redetermination Form."

For more Telephone Reopening information, go to






Incarcerated Medicare Beneficiaries

From June through August 2013, CMS initiated recoveries from providers and suppliers based on potentially incorrect data that indicated a beneficiary was incarcerated on the date of service. CMS announced that it has restored the original data on the Medicare Enrollment Data Base, is identifying all of the claims that were incorrectly demanded or collected, and is making changes to claims processing system utilities to effectuate the necessary changes. This automated process will identify the claims that were denied in error and reprocessing is expected to be completed by the Medicare Administrative Contractors by the end of December.

Contractors will not issue remittances for the corrected claims, but rather will provided physicians with a letter and spreadsheet containing details of the claims being reprocessed. Claims that were appealed will continue through the appeal process.